Stimulating neutrophil function to treat inflammatory bowel disease

ABSTRACT

Immune stimulatory amounts of hematopoietic colony stimulating factors are administered to patients with inflammatory bowel disease. The factors include G-CSF and GM-CSF. These factors induce and maintain remission of the disease and its manifestations, whether within the intestine or without.

[0001] This application claims the benefit of provisional applicationSerial No. 60/119,842 filed Feb. 12, 1999. The disclosure of theprovisional application is expressly incorporated by reference herein.

BACKGROUND OF THE INVENTION

[0002] Crohn's disease persists as an enigma: without a decipheredetiology and without adequate therapy. Prevailing explanations of thepathogenesis of Crohn's disease (Crohn's Disease) hold that thecharacteristic chronic intestinal inflammation results from an aberrant,activated immune response generated against ubiquitous bacteria orbacterial products that gain access to the lamina propria, perhapsthrough a more permeable intestinal barrier. The abnormal reaction hasbeen suggested to be mediated principally by T-cells enhanced by anintrinsic imbalance in pro-inflammatory and contra-inflammatorymediators. Thus, most therapy aims to counteract that inflammatory statewith increasingly potent and sophisticated immune suppressants.

[0003] Current therapy, mostly directed at suppressing the inflammatoryprocess, remains inadequate both for the treatment of flares andmaintenance of remission. Steroids can be effective in short term usebut produce dependency in a significant proportion of patients. Whilecertain antibiotics appear promising, data are limited. Thus there is aneed in the art for effective method for treating inflammatory boweldiseases.

SUMMARY OF THE INVENTION

[0004] It is an object of the invention to provide a method of treatingCrohn's Disease.

[0005] It is an object of the invention to provide a method of treatingUlcerative Colitis.

[0006] It is another object of the invention to provide a method oftreating extrainstestinal manifestations of Ulcerative Colitis orCrohn's disease.

[0007] It is still another object of the invention to provide a methodof treating pouchitis.

[0008] It is yet another object of the invention to treat and reduce therisk of fistula recurrence.

[0009] These and other objects of the invention are provided by one ormore of the embodiments described below. In one embodiment a method isprovided of treating Crohn's Disease in which an immune stimulatoryamount of an agonist of CD114 (Granulocyte Colony Stimulating FactorReceptor (G-CSFR)) is administered to a patient with Crohn's Disease notassociated with Glycogen Storage Disease 1b.

[0010] In another embodiment of the invention another method of treatingCrohn's Disease is provided. An immune stimulatory amount of an agonistof CD116 (Granulocyte-Macrophage Colony Stimulating Factor Receptor) orCDw131 is administered to a patient with Crohn's Disease not associatedwith Glycogen Storage Disease 1b.

[0011] In yet another embodiment of the invention another method isprovided of treating Crohn's Disease. An immune stimulatory amount of anagonist of CD114 (Granulocyte Colony Stimulating Factor Receptor(G-CSFR)) is administered to a patient with Crohn's Disease notassociated with Chronic Granulomatous Disease.

[0012] In still another embodiment of the invention a method is providedof treating Crohn's Disease in which an immune stimulatory amount of anagonist of CD116 (Granulocyte-Macrophage Colony Stimulating FactorReceptor) or CDw131 is administered to a patient with Crohn's Diseasenot associated with Chronic Granulomatous Disease.

[0013] In even another embodiment of the invention another method isprovided of treating Crohn's Disease. An immune stimulatory amount of anagonist of CD114 (Granulocyte Colony Stimulating Factor Receptor(G-CSFR)) is administered to a patient with Crohn's Disease notassociated with a presently characterized and identifiable specificneutrophil disorder caused by a genetic disease.

[0014] In yet another embodiment of the invention another method isprovided of treating Crohn's Disease. An immune stimulatory amount of anagonist of CD116 (Granulocyte-Macrophage Colony Stimulating FactorReceptor) or CDw131 is administered to a patient with Crohn's Diseasenot associated with a presently characterized and identifiable specificneutrophil disorder caused by a genetic disease.

[0015] According to another aspect of the invention a method is providedof treating Ulcerative Colitis. An immune stimulatory amount of anagonist of CD114 (Granulocyte Colony Stimulating Factor Receptor(G-CSFR)) is administered to a patient with Ulcerative Colitis.

[0016] According to another aspect of the invention a method is providedof treating Ulcerative Colitis. An immune stimulatory amount of anagonist of CD116 (Granulocyte-Macrophage Colony Stimulating FactorReceptor) or CDw131 is administered to a patient with UlcerativeColitis.

[0017] Another aspect of the invention is a method of treatingextraintestinal manifestations of Ulcerative Colitis. An immunestimulatory amount of an agonist of CD114 (Granulocyte ColonyStimulating Factor Receptor (G-CSFR)) is administered to a patient withextraintestinal manifestations of Ulcerative Colitis.

[0018] Another aspect of the invention is a method of treatingextraintestinal manifestations of Ulcerative Colitis. An immunestimulatory amount of an agonist of CD116 (Granulocyte-Macrophage ColonySimulating Factor Receptor) or CDw131 is administered to a patient withextraintestinal manifestations of Ulcerative Colitis.

[0019] According to still another aspect of the invention a method isprovided of treating pouchitis. An immune stimulatory amount of anagonist of CD114 (Granulocyte Colony Stimulating Factor Receptor(G-CSFR)) is administered to a patient with pouchitis.

[0020] According to still another aspect of the invention a method isprovided of treating pouchitis. An immune stimulatory amount of anagonist of CD116 (Granulocyte-Macrophage Colony Stimulating FactorReceptor) or CDw131 is administered to a patient with pouchitis.

[0021] According to still another aspect of the invention a method isprovided of preventing or reducing the risk of fistula recurrence. Animmune stimulatory amount of an agonist of CD114 (Granulocyte ColonyStimulating Factor Receptor (G-CSFR)) is administered to a patient withCrohn's disease who has previously had a fistula, whereby the risk ofrecurrence of a fistula is reduced

[0022] According to still another aspect of the invention a method isprovided of preventing or reducing the risk of fistula recurrence. Animmune stimulatory amount of an agonist of CD116 (Granulocyte-MacrophageColony Stimulating Factor Receptor) or CDw131 is administered to apatient with Crohn's disease who has previously had a fistula, wherebythe risk of recurrence of a fistula is reduced.

[0023] The present invention thus opens a new realm of treatmentmodalities for inflammatory bowel diseases which have proven refractoryto discovery of safe and effective ministrations. Contrary to the priorparadigm in the art of treating inflammatory bowel diseases withimmunosuppressive agents, the present invention uses agents known to beimmunostimulatory to treat, prevent, and maintain remission of suchdiseases.

BRIEF DESCRIPTION OF THE DRAWINGS

[0024]FIG. 1 shows the response of 17 patients to a 12-week regimen oftherapy with G-CSF.

[0025]FIG. 2 shows the response of patient D during treatment andretreatment.

DETAILED DESCRIPTION OF THE INVENTION

[0026] It is a discovery of the present inventors that immune modulatoryfactors which act at CD114, CD116, and or CDw131 can be successfullyused to treat various forms of inflammatory bowel disease. These includebut are not limited to Crohn's Disease, with or without a presentlycharacterized and identifiable specific neutrophil disorder (such asGlycogen Storage Disease 1b or Chronic Granulomatous Diseases)pouchitis, fistulas, extraintestinal manifestations of Crohn's Disease,and Ulcerative Colitis. The Ulcerative Colitis can be of any extent,including proctitis, proctosigmoiditis, left-sided colitis, orpan-colitis.

[0027] The immune modulatory factor can be any which binds to CD114,CDw131, or CD116, including G-CSF, GM-CSF, IL-3, IL-5, andpeptidomimetics or non-peptidomimetics of these factors which inducetyrosine phosphorylation of multiple signaling proteins, which stimulateprimary bone marrow cells to form granulocytic colonies in vitro, and/orwhich elevate peripheral blood neutrophil counts. Nartograstim,myelopoietins, circularly permuted G-CSF sequences, SB247464 are amongthe known mimetics of G-CSF. See, McWherter et al., Biochemistry 14:4564-71, 1999; Feng et al., Biochemistry 14: 4553-63, 1999; Tian et al.,Science 281: 257-59,1998; and Kuwabara et al., Am. J. Physiology271:E73-84, 1996. M-CSF may also be used in accordance with the presentinvention. The agonist may be administered as is known in the art.Typically this will be by subcutaneous injection or intravenousinfusion, however other methods such as oral, intraperitoneal,subdermal, and intramuscular administrations can be used. Doses whichare delivered may be the same as those which are delivered to stimulatean immune response in humans for other disease purposes. Typically dosesof the factors will be between about 0.1 and 100 μg/kg of body weightper day. More preferably this will be between about 1.0 and 10 μg/kg ofbody weight per day. Most preferably the dose will be between about 2and 8 μg/kg of body weight per day. Corresponding amounts ofpeptidomimetics and non-peptidomimetics to achieve the same activity canbe used. White blood cell counts can be monitored to maintain a value inthe range of 10 and 60.

[0028] The immune modulatory factors are typically growth factors orcolony stimulating factors which affect the growth of hematopoieticcells, particularly myeloid cells, including polymorphonuclearleukocytes, monocytes, and macrophages. Such factors include but are notlimited to myeloid cell stimulatory factors, polymorphonuclear leukocytestimulatory factors, and granulocytic cell stimulatory factors.Particularly useful factors are GCSF, GMCSF, and MCSF. Any form of suchfactors known in the art can be used. The form may be an isoform or adifferently post-translationally modified form of the factor. The factormay be one which is isolated from humans or other primates or mammals.The factor may be one which is made in a recombinant organism, frombacteria to yeast to sheep.

[0029] Diseases which are amenable to treatment as described hereininclude all within the umbrella of inflammatory bowel disease. Thephrase “Crohn's Disease not associated with disease X” as used heremeans that the patient that is being treated according to the method ofthe invention has not been diagnosed with disease X. Presentlycharacterized and identifiable specific neutrophil disorders caused bygenetic diseases include Chronic Granulomatous Disease, Glycogen storagedisease 1b, leukocyte adhesion deficiency, Turner's syndrome,Chediak-Higashi, myeloproliferative disease, neutropenias of variouscauses, and myelodysplastic disease. Ulcerative colitis can bemanifested as proctosigmoiditis, left-sided colitis, or pan-colitis. Allof these are included in the term “Ulcerative colitis”. Pouchitis is aninflammation of an surgically created pouch in the gastrointestinaltract.

[0030] One goal of treatment is the amelioration, either partial orcomplete, either temporary or permanent, of patient symptoms, includinginflammation of the mucosa, extraintestinal manifestations of thedisease, or epithelial damage. Any amelioration is considered successfultreatment. This is especially true as amelioration of some magnitude mayallow reduction of other medical or surgical treatment which may be moretoxic or invasive to the patient. Extraintestinal disease manifestationsinclude those of the liver, bile duct, eyes, and skin. Another goal ofthe treatment is to maintain a lack of excess intestinal inflammation inpersons who have already achieved remission.

[0031] The present invention is based on the theory that the fundamentalimmune dysregulation of Crohn's Disease results not from an excessiveimmune response but from a primary immune deficiency. This deficiencylikely results from genetic variations in neutrophil and/or macrophagephenotypes interacting with a discrete set of bacteria which suppressneutrophil/macrophage function. In turn, this deficiency provokes abroader compensatory response, amplifying inflammation, activatinglymphocytes, culminating in Crohn's Disease.

[0032] The recent account of patients experiencing prolonged remissionafter allogeneic bone marrow transplant (BMT) suggests that the marrowphenotype may be central to the pathogenesis of Crohn's Disease. Fivepatients with Crohn's Disease and chronic myelogenous leukemia underwentBMT with recurrence of Crohn's Disease in only one patient who remainedchimeric with native and transplanted marrow. Conversely, the recurrenceof Crohn's Disease in transplanted small bowel reinforces the idea thata critical factor in the development of Crohn's Disease may beextraintestinal, perhaps partly an intrinsic marrow defect, and thatCrohn's Disease is not an inherent intestinal abnormality. Consequently,Crohn's Disease ought to be considered not as a disease of primaryintestinal dysfunction but the result of an interaction between marrowconstituents and the intestinal environment.

[0033] Several genetic syndromes with which Crohn's Disease has beenassociated provide insight into the possible marrow defects of Crohn'sDisease. In particular, five genetic diseases can present with aclinical/histopathological process indistinguishable from Crohn'sDisease: chronic granulomatous disease, glycogen storage disease 1b,Leukocyte Adhesion Deficiency, Chediak-Higashi syndrome and Turner'ssyndrome. A distinct deficiency in neutrophil function has beendescribed in each of these syndromes. In addition, Crohn's Disease hasbeen described in association with congenital, autoimmune, and cyclicneutropenias, familial Mediterranean fever, myelodysplastic, andmyeloproliferative diseases. The diagnosis of leukemia preceded Crohn'sDisease in nearly half the cases in the largest series and diagnosis ofmyelodysplasia and Crohn's Disease was made concomitantly in half thesubjects in another study suggesting a possible causal relationship forthe development of Crohn's Disease initiated by an accumulation ofdysfunctional neutrophils. These syndromes provide evidence that avariety of functional neutrophil deficiencies can result in apathophysiology indistinguishable from Crohn's Disease. Disorders ofneutrophil/macrophage function represent a potential starting point forunderstanding Crohn's Disease.

[0034] A role for intestinal flora has been established in Crohn'sDisease. Reinforced by other evidence, the importance of the microflorahas been demonstrated by the provocation of inflammation with the directintroduction of ileostomy output into a defunctionalized intestinalsegment while a sterile, filtered fraction fails to induce diseaseactivity. While this response is considered non-specific to ubiquitousbacteria, specific alterations in the fecal flora have been identifiedin patients with Crohn's Disease compared to healthy controls. InCrohn's Disease, Bacteroides tend to be present in increased amountswhile Lactobacillus and Bifidobacteria are diminished, though results ofstudies are not unanimous. Some Bacteroides species have been shown toimpair phagocytosis as well as the microbicidal activity of neutrophilsfor aerobic bacteria. A discrete subset of the intestinal flora may beresponsible for influencing neutrophil/macrophage function in Crohn'sDisease. Recent work with animal models of IBD also support a protectiverole for Lactobacillus and Bifidobacteria which may act to countereffects of other bacteria and stimulate immune function. The ratiobetween these different classes of bacteria may be the critical factorin maintaining intestinal health in a susceptible subgroup.Consequently, as suggested by periodontitis, it is unlikely that asingle bacteria would be demonstrated as the sole causative agent inCrohn's Disease; instead, these data highlight the complexity ofbacterial-immune interactions. The localized nature of the interactionbetween specific bacteria and leukocytes would account for the specificintestinal manifestations, rather than more systemic findings.

[0035] Any explanation of the Crohn's Disease must account for thedisease as a twentieth century phenomena in industrialized countries.The disease appears at best rare before Crohn's defining publication in1932. One possible, relevant, radical change in the past half centurymay be a shift in intestinal flora. Twentieth century innovations infood preservation with the introduction of refrigeration and othertechniques may have produced a fundamental change in the type and amountof bacteria ingested, and may alter the intestinal bacterial content. Incomparison to intestinal flora in rural Africa where Crohn's Diseaseremains rare, the gut flora of westernized countries contain higherconcentrations of Bacteroides as well as decreased amounts ofBifidobacteria, perhaps predisposing the intestinal environment toimpair the host immune response and set the stage, in the susceptiblehost, for the development of Crohn's Disease.

[0036] While the human intestinal bacterial flora resists alteration, itcan be manipulated. Once established in infancy, the bacterial floraundergoes some changes after weaning but remains remarkably constantthroughout life. The protective role of breast feeding against thedevelopment of Crohn's Disease may be through promoting Bifidobacteriain higher concentrations and limiting Bacteroides, an effect which hasbeen well documented. The demonstrated association of increased refinedcarbohydrate intake with Crohn's Disease may be explained through itsinfluence on gut flora as well.

[0037] While a change in flora in the susceptible host may alone besufficient and an important result of the westernized lifestyles, otherfactors are likely contributory. The rise in the latter half of thiscentury of smoking and non-steroidal anti-inflammatory drug (NSAID) use,risk factors for Crohn's Disease, may be in part responsible for theincrease in Crohn's Disease, though the nature of their influence on thepathophysiology remains uncertain. While several actions of nicotinehave been advanced for its influence on Crohn's Disease, nicotine'sprimary detrimental effect may be on neutrophil function, an effectwhich has been repeatedly demonstrated. Likewise, though numerousmechanisms have also been proposed for the deleterious effects of NSAIDson patients with IBD, NSAIDs impairment of neutrophil function may becentral to their impact on Crohn's Disease. These factors, eachsuppressing immune function, may potentiate the same pathway and promotethe development or persistence of Crohn's Disease.

[0038] The GM-CSF receptor is composed of two subunits:

[0039] 1) Hs. 182378 colony stimulating factor 2 receptor, alpha,low-affinity (granulocyte-macrophage) CSF2RA (CD116) GM-CSF receptoralpha chain

[0040] The primary binding subunit of the GM-CSF receptor.

[0041] CD116 is a Type I transmembrane protein with about 400 aminoacids. Extracellular, transmembrane and cytoplasmic domains consist of297, 27, and 54 amino acid residues, respectively. There is one unit ofclass I cytokine receptor motif in the extracellular domain and nointrinsic enzymatic activity in the cytoplasmic domain. A number ofisoforms are generated by alternative splicing of several soluble forms.All the isoforms are relatively minor species and their physiologicalfunction if any is not known. One is a soluble form without thetransmembrane domain and the second form is identical to the originalone except that the last 25 amino acids of the original receptor issubstituted by a 35 amino acids segment

[0042] CD116 binds GM-CSF with low affinity and binds it with highaffinity when it is co-expressed with the common beta subunit CDw131(the common beta subunit (CDw131) of the GM-CSF, IL-3, and IL-5receptors). Expression of this subunit is found in various myeloid cellsincluding macrophages, neutrophils, eosinophils, dendritic cells andtheir precursors.

[0043] Tavernier et al. (1991) demonstrated that the high affinityreceptor for interleukin-5 (IL5R; 147851) and the receptor forgranulocyte-macrophage CSF (CSF2R; 306250) share a beta chain. Thefinding provides a molecular basis for the observation that IL5 (147850)and CSF2 (138960) can partially interfere with each other's binding andhave highly overlapping biologic activities on eosinophils. Kitamura etal. (1991) demonstrated that the receptor for interleukin-3 (IL3RA;308385) likewise shares a beta subunit with CSF2R.

[0044] 2) Hs.265262 colony stimulating factor 2 receptor, beta,low-affinity (granulocyte-macrophage) CSF2RB*

[0045] (CDw131) Alternate names for CDw 131 are common beta subunitINTERLEUKIN 5 RECEPTOR, BETA; IL5RB INTERLEUKIN 3 RECEPTOR, BETA; IL3RB*138981 GRANULOCYTE-MACROPHAGE COLONY-STIMULATING FACTOR RECEPTOR, BETA;CSF2RB

[0046] CDw131 does not bind any cytokine by itself However, it is acomponent of the high affinity IL-3, GM-CSF and IL-5 receptors. CDw131is tyrosine phosphorylated upon binding of these cytokines to the highaffinity receptors. JAK2 tyrosine kinase is associated with CDw131 andtyrosine phosphorylates upon stimulation. Tyrosine phosphorylated CD131binds various signaling molecules with an SH2 domain. These include Shc,Grb2, SHP1, SHP2, P13 kinase and STAT5, making it a key signaltransducing molecule of the IL-3, GM-CSF and IL-5 receptors.

[0047] The following references are expressly incorporated herein fortheir teachings regarding the common beta subunit of these receptors:

[0048] Dirksen, U.; Nishinakamura, R.; Groneck, P.; Hattenhorst, U.;Nogee, L.; Murray, R.; Burdach, S. : Human pulmonary alveolarproteinosis associated with a defect in GM-CSF/IL-3/IL-5 receptor commonbeta chain expression. J. Clin. Invest. 100: 2211-2217, 1997.

[0049] Jenkins, B. J.; D'Andrea, R.; Gonda, T. J.: Activating pointmutations in the common beta subunit of the human GM-CSF, IL-3 and IL-5receptors suggest the involvement of beta subunit dimerization andcelltype-specific molecules in signalling. EMBO J. 14: 4276-4287, 1995.

[0050] Kitamura, T.; Sato, N.; Arai, K.; Miyajima, A.: Expressioncloning of the human IL-3 receptor cDNA reveals a shared beta subunitfor the human IL-3 and GM-CSF receptors.

EXAMPLES Example 1

[0051] This example shows the treatment of 3 Crohn's disease patientswith GM-CSF. All three meet the definition of treatment response (CDAIdecrease of greater than 70). Patients 2 and 3 are very early in theirtreatments and it appears likely that they will go into remission. Theprotocol employed is described below. Patient 1 Pretreatment CDAI: 340.4Week 1 CDAI: 344.4 Week 2 CDAI: 285.6 Week 3 CDAI: 286.6 Week 5 CDAI:276.4 Week 6 CDAI: 299.4 Week 8 CDAI: 209.2 Patient 2 Pretreatment CDAI:349.6 Week 1 CDAI: 274.0 Week 2 CDAI: 227.0 Week 3 CDAI: 216.6 Patient 3Pretreatment CDAI: 410.8 Week 1 CDAI: 299.0 Week 2 CDAI: 231.4

Example 2

[0052] This example demonstrates the treatment of 17 Crohn's diseasepatients with G-CSF.

[0053] Subjects were enrolled with active disease (CDAI>200) or withactive fistulous disease. Patients were not included if otherimmunosuppressants had been used for standard periods of time (4 weeksfor steroids, azathioprine/6-MP; 3 months for infliximab) and wereallowed to be on 5-ASA products (if on for at least 8 weeks and samedose for at least 4 weeks). Subjects had a complete blood count (CBC)test weekly and were examined at least every other week for Crohn'sDisease activity index (CDAI) determination and/or evaluation offistulae. FIG. 2 shows the Crohn's Disease Activity Index (CDAI) at theonset (week 0) and followed over a 12-week course of treatment. Clinical“response” in Crohn's disease protocols is typically defined as adecrease in CDAI greater than 70. Ten of the 17 patients wereresponders, with a mean decrease in disease activity of 140 points.Seven of the ten achieved remission. Seven non-responders, includingpatient M who was withdrawn early from the study for concurrent illness,had a mean increase in CDAI of 41 points. Spontaneous closure ofperianal fistulas is very rare. Our cohort included three patients withperianal fistula. At completion of therapy, all three patients hadfistulas which closed. Conversion of a draining fistula to an abscess(seen˜10% of the time with Infliximab treatment) occurred in onepatient. This is believed to reflect closure of the fistula tract at theskin before closure of the internal opening to the intestine. Increasingdisease activity in several patients as G-CSF was tapered (per originalprotocol), suggested the possibility of a dose response effect.Accordingly, the protocol was amended for different dosing and to permitpatient re-treatment. FIG. 3 shows the overall treatment course forpatient D. A dramatic improvement resulted from the initial 12 weekG-CSF course, coupled with a significant decrease in erythrocytesedimentation index (ESR, a non-specific marker for inflammation).Discontinuation of therapy between weeks 12 to 16 was associated withincreasing disease activity, which again rapidly responded toreinstitution of G-CSF therapy.

Example 3

[0054] This example shows the protocol for a further study of the methodof the present invention using G-CSF

[0055] An open-labeled trial of G-CSF for 12 weeks for patients withactive CD and/or active fistulae secondary to Crohn's disease isinitiated. The trial involves two separate, interrelated protocols. Inconjunction with this treatment protocol, functional neutrophil studiesare performed.

[0056] Treatment of active mucosal inflammation in Crohn's disease isthe primary focus of Part A. Disease activity is defined by a standardCrohn's disease activity index. Patients are enrolled if they havemoderate to severe disease activity using entry criteria outlined below.The study is an open-labeled study of fifteen patients with a dosetitration protocol designed to provide neutrophil functional stimulationand achieve a moderate leukocytosis. Each subject is studied for twelveweeks of every day subcutaneous administration of G-CSF. Diseaseactivity is followed by standard CDAI, and the quality of life (IBDQ)scale. We are treating new patients (those not included in our initialstudy) and offer retreatment to any of the previously treated mucosapatients meeting inclusion criteria.

[0057] The primary focus of Part B is to determine the efficacy of G-CSFin patients with perianal and rectovaginal fistula associated withCrohn's disease. Perianal fistulae are common lesions in Crohn's diseaseand pose a serious threat to the integrity of the normal rectalsphincter. Current therapy for these lesions are suboptimal. This studyis designed as an open-labeled study of fifteen patients with a dosetitration protocol designed to stimulate neutrophil function andassociated leukocytosis. Fistulae are assessed by photography, standardexamination scoring criteria, as well as a patient subjective assessmentof pain, drainage, and overall well-being. Each subject is studied fortwelve weeks on daily subcutaneous G-CSF. Disease activity is alsomonitored by standard CDAI, and the quality of life (IBDQ) scale.

[0058] On the basis of extensive investigational and ongoinginternational clinical experience with G-CSF, the safety profile is wellknown. In addition, several patients with active Crohn's disease orCrohn's like intestinal disease have been reported in the medicalliterature who have been successfully treated (for coexisting disorders)with GM-CSF or G-CSF without any serious or significant adverse effects.Based on the extensive clinical experience with G-CSF and thepreliminary evidence of the reported cases, no predictable risks areanticipated at the doses studied. Nevertheless, as this is a new andcounterintuitive approach to a chronic inflammatory disease, we areclosely monitoring patients for safety and any adverse effects duringthis protocol.

[0059] Treatment Groups

[0060] Part A. Treatment of moderate to severe Crohn's disease. Patientsare assigned to receive a starting dose of 3.5 micrograms/kilogram/dayof G-CSF as a subcutaneous bolus injection. Dosages are adjusted asoutlined below, “ANC response-based dosing of G-CSF.” Treatmentcontinues for 12 weeks. CDAI is calculated at enrollment, at the startof therapy, and every other week. The Inflammatory Bowel Disease Qualityof Life Survey is completed initially and at weeks four, eight, twelve,and sixteen. Follow-up is performed at week 16 with telephone follow-upmonthly out to six months from the date of enrollment or up to relapse.

[0061] Part B. Treatment of perianal and rectovaginal fistula in Crohn'sdisease. Patients are assigned to receive a starting dose of 3.5micrograms/kilogram/day of G-CSF as a subcutaneous bolus injection.Dosages are adjusted as outlined below—“ANC response-based dosing ofG-CSF.” Patients who have closed all fistulae before week 8, have G-CSFtherapy discontinued at 8 weeks. Patients who have had partial or noresponse are treated for a full twelve weeks. Fistulae are assessed atweeks 0, 1, 2,4, 6, 8 and 12 by physical examination scoring criteria,photography, and a subjective patient survey. CDAI is calculated atenrollment, at the start of therapy, and every other week. TheInflammatory Bowel Disease Quality of Life Survey is completed initiallyand at weeks four, eight, twelve, and sixteen. Follow-up is performed atweek 16 with telephone follow-up monthly out to six months from the dateof enrollment or up to relapse.

[0062] Inclusion Criteria

[0063] 1) Age greater than or equal to 18 years old.

[0064] 2) History of Crohn's disease for at least three months withextent of disease described endoscopically or radiologically within thepast three years. Patients in Part B must have had previouscharacterization of their perianal disease (e.g., clinical exam, examunder anesthesia (EUA), magnetic resonance imaging, or CT scan).

[0065] 3) Part A: Crohn's Disease Activity Index (CDAI)>200 and <450.Part B: At least 1 draining perianal and/or rectovaginal fistula,refractory to general medical management. Previously treated patientswho have had a previous response or remission are eligible forretreatment if they have evidence of increased disease activity manifestby reopening of previously closed fistulas (Part B) or who have a CDAIof >220 and have an absolute increase of more than 70 from the treatmentnadir (Part A).

[0066] 4) If on aminosalicylate medication (Sulfasalazine, Pentasa,Asacol, Dipentum, Rowasa enemas), must be on for eight weeks and astable dose for four weeks. If recently discontinued, must be off for atleast two weeks prior to study enrollment.

[0067] 5) If using oral corticosteroids, patients must have been usingthem for more than 8 weeks, and been on a stable dose (<20 mg/day ofprednisone equivalent) for at least 4 weeks prior to trial enrollment.

[0068] 6) Patients must be off antibiotics for at least two weeks, or ifon antibiotics, therapy must be for at least 8 weeks and the patientmust be on a stable dose for 4 weeks. Antibiotic use at any time forreasons other than Crohn's disease (e.g. urinary tract infection) isallowed.

[0069] 7) If female and pre-menopausal, a negative serum beta-HCG mustbe obtained at the screening visit and use of one of the following formsof contraception must be documented: diaphragm, condom, cervical cap,abstinence or surgical tubal ligation. Patients must agree to useadequate birth control methods until at least 2 months after the lastdose of G-CSF.

[0070] 8) Negative stool tests for routine culture and sensitivity, ovaand parasites, and C. difficile toxin.

[0071] 9) Written informed consent has been obtained and patients mustbe able to adhere to the study visit schedule and protocol.

[0072] Exclusion Criteria

[0073] 1) NSAID or ASA ingestion within two weeks of study entry.

[0074] 2) GI surgery within three months of entry into study.

[0075] 3) Use of azathioprine, 6-MP, methotrexate or any other immunesuppressant in the previous four weeks. Use of infliximab (Remicade)within the previous 12 weeks. Use of any investigation agent (aside fromG-CSF) within the previous four weeks or five half-lives of the studymedication, whichever is longer.

[0076] 4) Presence of an ostomy in the mucosa arm. Ostomies are allowedin the fistula arm—a modified CDAI is applied.

[0077] 5) A patient with any of the following medical conditions: Liverdisease with a prothrombin time>2 second prolongation, portalhypertension, severe hypertension (systolic blood pressure>200 mmHg or adiastolic blood pressure>105 mmHg), renal failure requiring dialysis ora creatinine>2.5, presence of a transplanted organ.

[0078] 6) Patients with a known, clinically significant, small intestineor colonic stenosis or stricture.

[0079] 7) A history of leukemia or lymphoma, or otherlymphoproliferative disease, or signs and symptoms oflymphoproliferative disease such as abnormal cells on CBC, or suggestivephysical exam findings of lymphadenopathy of unusual size or location.

[0080] 8) Evidence of abscess or active Crohn's disease relatedinfections in need of surgical drainage

[0081] 9) Known recent substance abuse (drugs or alcohol).

[0082] 10) History of gout.

[0083] 11) Significant unexplained abnormalities in any of theprescreening blood work.

[0084] 12) Known hypersensitivity to E. coli-derived proteins.

[0085] Physician Visits

[0086] New patients are screened within 14 days of initiating themedication with a history, physical and recall estimation of a Crohn'sdisease activity index (CDAI). If the estimated CDAI is >200 and <450,subjects have a CBC drawn, beta-HCG (if female and premenopausal) andcomplete a diary for 1 consecutive week within the next 14 days. Thesubject will return for initiation at day 0. If subject meetsentry/exclusion criteria, blood is drawn for CBC, electrolytes, BUN,creatinine, liver enzymes (AST, ALT, alkaline phosphatase, bilirubin),albumin, ESR, and CRP. Instruction is provided for self-administrationof the medication (subcutaneous injection). Subjects are titrated to astable WBC response. Patients are seen and examined by a physician onweeks 0, 1, 2, 4, 6, 8, 10, 12, and for the required post treatmentvisit at week 16. A daily diary is completed throughout the period ofadministration of the medication. Telephone calls are performed monthly,starting at the conclusion of G-CSF therapy and continued through sixmonths to assess disease activity and adverse effects. At each visit,patients are provided a sufficient supply of medication to continueadministration through the next visit.

[0087] Laboratory Blood Tests

[0088] CBC are performed at screening, at the times indicated by theflow sheet during treatment, and at the scheduled visit 4 weeks aftercompletion of therapy. A panel of serum chemistry studies (electrolytes,BUN, creatinine, liver enzymes (AST, ALT, alkaline phosphatase,bilirubin) is measured at screening, and at weeks 4, 8, 12, and 16.C-Reactive Protein (CRP) and erythrocyte sedimentation rate (ESR) aremeasured at week 0, 2, 4, 8, 12, and 16. Laboratory results that deviatesignificantly from baseline (except the WBC and alkaline phosphatase)are repeated by obtaining new samples.

[0089] ANC response-based dosing of G-CSF

[0090] Initial dose: 3.5 micrograms per kilogram per day SQ. Doses arebased on the patient enrollment weight.

[0091] Decreases based on HIGH ANC:

[0092] Patients with an ANC>60,000/mm³ (60.0×10⁹/L) have their dosedecreased by 1.0 micrograms per kilogram per day. Otherwise, subsequentdose adjustments are made in 0.5 mcg/kg/day increments. CBC withdifferential are drawn in one week. Subsequent dose modifications aremade as follows.

[0093] 1. For a patient with an ANC>50,000/mm³, the next scheduled doseis lowered by 0.5 mcg/kg/day. The ANC is rechecked in 1 week.

[0094] 2. For a patient with an ANC of between 40-50,000/mm³, the nextscheduled dose is kept the same. The ANC is rechecked in 1 week.

[0095] 3. For a patient with two consecutive ANC measurements between40-50,000/mm³, the next ANC measurement is performed at the nextscheduled physician visit.

[0096] Increases based on LOW ANC

[0097] Patients with an ANC<30,000/mm³ (30.0×10⁹/L) have their doseincreased by 1.0 micrograms per kilogram per day. CBC with differentialare drawn in one week. Subsequent dose modifications are made asfollows.

[0098] 1. For a patient with an ANC <40,000/mm³, the next scheduled doseis increased by 0.5 mcg/kg/day. The ANC is rechecked in 1 week.

[0099] 2. For a patient with an ANC of between 40-50,000/mm³, the nextscheduled dose is kept the same. The ANC is rechecked in 1 week.

[0100] 3. For a patient with two consecutive ANC measurements between40-50,000/mm³, the next ANC measurement is performed at the nextscheduled physician visit.

[0101] Physicians may decrease dosages as necessary due to severe bonepain. Once the ANC has been in the target range (40-50) on twoconsecutive measurements, monitoring is increased to the next scheduledphysician visit. Physician or nurse coordinators review the CBC resultsand call the patient with any dosage change.

Example 4

[0102] This example shows the protocol for a further study of the methodof the present invention using GM-CSF.

[0103] An open-labeled, pilot, dose escalation study of GM-CSF isperformed in patients with CD. Fifteen patients are enrolled with activedisease (Crohn's Disease Activity Index—CDAI>200 and <450). Patients arerequired not to have used steroids, azathioprine of other immunemodulator for four weeks. NSAID use is not allowed for two weeks priorto or throughout the study. An open-labeled dose escalation study isconducted in three groups of five (4 mcg/kg/day; 6 mcg/kg/day; 8mcg/kg/day) Neutrophil function is tested before the initiation ofGM-CSF and at week eight (two weeks after the completion of six weeks ofadministration of the medication) to assess neutrophil chemotaxis andsuperoxide production. CBC is examined on day 0, 7 and then weeklyexcept for week 5. C-Reactive Protein (CRP) and erythrocytesedimentation rate (ESR) is examined every two weeks. Patients areexamined weekly during the trial with telephone calls once a week aswell for safety monitoring. Patients complete a daily diary throughoutthe study. CDAI is calculated weekly and an Inflammatory Bowel DiseaseQuality of Life Survey is completed at week 0, week four and week eight.Follow-up is performed at week 8, and 12 with telephone follow-upmonthly for six months.

[0104] Inclusion criteria:

[0105] 1) Age over 16 years old.

[0106] 2) History of Crohn's disease for at least three months withextent of disease described endoscopically or radiologically within thepast two years.

[0107] 3) Crohn's disease activity index>200 and <450.

[0108] 4) If on a mesalamine medication (sulfasalazine, Pentasa, Asacol.Dipentum, Rowasa enemas), must be on for eight weeks and a stable dosefor four weeks.

[0109] 5) If on antibiotics, must be on stable doses for at least sixweeks.

[0110] 6) If female and pre-menopausal, a negative serum beta-HCG mustbe obtained at the screening visit and use of one of the following formsof contraception must be documented: diaphragm, condom, cervical cap,abstinence or surgical tubal ligation.

[0111] 7) Negative stool tests for routine culture and sensitivity andC. difficile assay.

[0112] 8) Written informed consent has been obtained.

[0113] Exclusion criteria:

[0114] 1) NSAID or ASA ingestion within two weeks of study entry.

[0115] 2) GI surgery within three months of entry into study.

[0116] 3) Use of steroids, azathioprine, 6-MP, methotrexate or any otherimmune suppressant in the previous four weeks. Use of infliximab(Remicade) within the previous 12 weeks. Use of any investigation agentwithin the previous four weeks or five half-lives of the studymedication, whichever is longer.

[0117] 4) Presence of an ostomy.

[0118] 5) A patient with any of the following medical conditions: Liverdisease with a prothrombin time>2 second prolongation; portalhypertension; severe hypertension (systolic blood pressure>200 mmHg or adiastolic blood pressure>105 mmHg); renal failure requiring dialysis ora creatinine>2.5.

[0119] 6) Patients with a clinically significant tight small intestineor colonic stenosis or stricture.

[0120] 7) A history of leukemia or lymphoma

[0121] Physician Visits

[0122] Subjects are screened within 14 days of initiating the medicationwith a history, physical and recall estimation of a Crohn's diseaseactivity index (CDAI). If the estimated CDAI is >200 and <450, subjectshave a CBC drawn, beta-HCG if female and premenopausal) and complete adiary for I consecutive week within the next 14 days. The subjectreturns for initiation at day 0. If subject meets entry/exclusioncriteria, blood is drawn for CBC, BUN, creatinine, liver enzymes (AST,ALT, alkaline phosphatase, bilirubin), Albumin, ESR, CRP and neutrophilstudies (see section below). Instruction is provided forself-administration of the medication (IM injection). Subject visitsweekly except for week five. Visits are required at week 8 and 12. Adaily diary is completed throughout the period of administration of themedication. Telephone calls are performed weekly during the medicationperiod through week 8 and monthly through six months to assess diseaseactivity and adverse effects. At each visit, patients are provided asufficient supply of medication in preloaded syringes to continueadministration through the next physician visit.

[0123] Dose adjustment

[0124] Patients with an absolute neutrophil count of >30,000 have doseheld for 3 days when a CBC rechecked. If the ANC is <30,000 the dose isresumed at 2 mcg/kg/day lower than the dose administered when theleukocytosis occurred.

[0125] Study Failure

[0126] Patients are considered to have failed therapy if their CDAIincreases by >125 points on two separate occasions during the study ordeteriorates in any way considered significantly worse by thephysicians.

[0127] Assessment of Treatment Efficacy

[0128] Assessment is determined by a decrease in CDAI with remissionconsidered a CDAI<150 and in significant improvement considered adecrease of at least 70 points. Treatment failure is consideredinability to tolerate the therapy, a worsening of disease (more than 100points) or need to use additional medication for management of Crohn'sdisease. IBDQ is also performed at 3 time points: at initiation oftherapy at week 3 and at week 6. Note: CDAI is calculated with andwithout febrile episodes. As GM-CSF can induce febrile episodes, theCDAI, which includes fevers as one extra intestinal manifestation in thecalculation of disease activity score, for calculating the index, iscalculated with and without fevers assessed. Entry criteria arecalculated including febrile episodes.

[0129] Possible Adverse Events

[0130] The principal concern is lack of effect or an exacerbation ofdisease. The serious toxicities reported have been associated with dosesgreater than 10 mcg/kg/day. Systemic symptoms were identified in 27% ofpatients in a review of 295 patients in phase I and phase II studies.Bone pain (21%) and fever (18%) were the most commonly reported eventsthough these symptoms were severe in <2% of patients. Fevers can bewell-managed with acetaminophen. These reactions are less common atdoses proposed in this protocol. Skin reactions at sites of subcutaneousinjection are usually mild or moderate and resolve on discontinuation.The range of doses to be tested here is 4-8 mcg/kg/day.

[0131] Patients receiving GM-CSF (Sargramostim) have experienced fever;chills; nausea; vomiting; diarrhea; fatigue; weakness; headache;decreased appetite; thrombosis; rapid or irregular heartbeat or otherheart problems; feeling of faintness; facial flushing; pain in thebones, muscles, chest abdomen, or joints; local reaction at the site ofinjection; rashes; and kidney and liver dysfunction.

[0132] There have been infrequent reports of fluid accumulation orworsening of pre-existing fluid accumulation in the extremities, in thelungs, and around the heart which may result in breathing problems orheart failure. Rarely, patients have developed acute allergic reactions.There have been reports of low blood pressure, hypoxia (low oxygen),transient loss of consciousness, and difficulty in breathing after thefirst injection of Sargramostim. These signs may or may not recur withadditional injections of Sargramostim. Patients with prior heart, lung,kidney or liver problems may have worsening of their symptoms followingadministration of Sargramostim. There may be other side effects thatcould occur.

1. A method of treating Crohn's Disease comprising: administering to apatient with Crohn's Disease not associated with Glycogen StorageDisease 1b an immune stimulatory amount of an agonist of CD114(Granulocyte Colony Stimulating Factor Receptor (G-CSFR)).
 2. A methodof treating Crohn's Disease comprising: administering to a patient withCrohn's Disease not associated with Glycogen Storage Disease 1b animmune stimulatory amount of an agonist of CD116 (Granulocyte-MacrophageColony Stimulating Factor Receptor (GM-CSFR)).
 3. A method of treatingCrohn's Disease comprising: administering to a patient with Crohn'sDisease not associated with Chronic Granulomatous Disease an immunestimulatory amount of an agonist of CD114 (Granulocyte ColonyStimulating Factor Receptor (G-CSFR)).
 4. A method of treating Crohn'sDisease comprising: administering to a patient with Crohn's Disease notassociated with Chronic Granulomatous Disease an immune stimulatoryamount of an agonist of CD116 (Granulocyte-Macrophage Colony StimulatingFactor Receptor (GM-CSFR)).
 5. A method of treating Crohn's Diseasecomprising: administering to a patient with Crohn's Disease notassociated with a presently characterized and identifiable specificneutrophil disorder caused by a genetic disease an immune stimulatoryamount of an agonist of CD114 (Granulocyte Colony Stimulating FactorReceptor (G-CSFR)).
 6. A method of treating Crohn's Disease comprising:administering to a patient with Crohn's Disease not associated with apresently characterized and identifiable specific neutrophil disordercaused by a genetic disease an immune stimulatory amount of an agonistof CD116 (Granulocyte-Macrophage Colony Stimulating Factor Receptor(GM-CSFR)).
 7. A method of treating pouchitis comprising: administeringto a patient with pouchitis an immune stimulatory amount of an agonistof CD114 (Granulocyte Colony Stimulating Factor Receptor (G-CSFR)).
 8. Amethod of treating pouchitis comprising: administering to a patient withpouchitis an immune stimulatory amount of an agonist of CD116(Granulocyte-Macrophage Colony Stimulating Factor Receptor (GM-CSFR)).9. A method of preventing or reducing the risk of fistula recurrence,comprising: administering to a patient with Crohn's disease who haspreviously had a fistula, with an immune stimulatory amount of anagonist of CD114 (Granulocyte Colony Stimulating Factor Receptor(G-CSFR)), whereby the risk of recurrence of a fistula is reduced.
 10. Amethod of preventing or reducing the risk of fistula recurrence,comprising: administering to a patient with Crohn's disease who haspreviously had a fistula, with an immune stimulatory amount of anagonist of CD116 (Granulocyte-Macrophage Colony Stimulating FactorReceptor (GM-CSFR)), whereby the risk of recurrence of a fistula isreduced.
 11. The method of claim 1, 2, 3, 4, 5, or 6 wherein the patienthas mucosal inflammatory disease of at least one of the small intestine,colon, or rectum, and the amount of colony stimulating factoradministered is sufficient to reduce the mucosal inflammation.
 12. Themethod of claim 11 wherein the amount of colony stimulating factoradministered is sufficient to induce remission of the mucosal disease.13. The method of claim 1, 2, 3, 4, 5, or 6 wherein the patient hasepithelial damage of at least one of the small intestine, colon, orrectum, and the amount of colony stimulating factor administered issufficient to repair the epithelial damage.
 14. The method of claim 1,2, 3, 4, 5, or 6 wherein the amount of colony stimulating factoradministered is sufficient to reduce the patient's symptoms.
 15. Themethod of claim 1, 2, 3, 4, 5, or 6 wherein the patient has a fistula ora perianal abscess, and the amount of colony stimulating factoradministered is sufficient to reduce the fistula or perianal abscess.16. The method of claim 1, 2, 3, 4, 5, or 6 wherein the patient is inremission.
 17. The method of claim 1, 2, 3, 4, 5, or 6 wherein thepatient has received surgical therapy of affected portions of thegastrointestinal tract.
 18. The method of claim 1, 2, 3, 4, 5, or 6wherein the patient has an extraintestinal manifestation of Crohn'sdisease and the amount of colony stimulating factor administered issufficient to reduce the extraintestinal manifestation.
 19. The methodof claim 18 wherein the extraintestinal manifestation is an inflammatoryeye disorder.
 20. The method of claim 19 wherein the inflammatory eyedisorder is selected from the group consisting of: iritis, uveitis, andepiscleritis.
 21. The method of claim 19 wherein the extraintestinalmanifestation a skin disorder.
 22. The method of claim 21 wherein theskin disorder is selected from the group consisting of: pyodermagangrenosum and erythema nodosum.
 23. The method of claim 18 wherein theextraintestinal manifestation is a liver disorder.
 24. The method ofclaim 23 wherein the liver disorder is primary sclerosing cholangitis.25. The method of claim 18 wherein the extraintestinal manifestation isbile duct disease.
 26. The method of any of claims 1 to 10 wherein areduced dose of an immunosuppressive agent is also administered to thepatient.
 27. The method of claim 26 wherein the agent is selected fromthe group consisting of: corticosteroid, 6-mercaptopurine, azathioprine,and methotrexate.
 28. The method of claim 18 wherein the extraintestinalmanifestation is stomach inflammation.
 29. The method of claim 18wherein the extraintestinal manifestation is esophageal disease.
 30. Themethod of claim 1, 3, 5, 7, or 9 wherein the agonist is G-CSF.
 31. Themethod of claim 2, 4, 6, 8, or 10 wherein the agonist is GM-CSF.
 32. Themethod of claim 1, 3, 5, 7, or 9 wherein the agonist is a peptidomimeticof G-CSF.
 33. The method of claim 1, 3, 5, 7, or 9 wherein the agonistis a non-peptidomimetic of G-CSF.
 34. A method of treating Crohn'sDisease comprising: administering to a patient with Crohn's Disease notassociated with Glycogen Storage Disease 1b an immune stimulatory amountof an agonist of CDw131 (the common beta subunit of the receptors forGM-CSF, IL-3, and Il-5).
 35. A method of treating Crohn's Diseasecomprising: administering to a patient with Crohn's Disease notassociated with Chronic Granulomatous Disease an immune stimulatoryamount of an agonist of CDw131 (the common beta subunit of the receptorsfor GM-CSF, IL-3, and Il-5).
 36. A method of treating Crohn's Diseasecomprising: administering to a patient with Crohn's Disease notassociated with a presently characterized and identifiable specificneutrophil disorder caused by a genetic disease an immune stimulatoryamount of an agonist of Cdw131 (the common beta subunit of the receptorsfor GM-CSF, IL-3, and Il-5).
 37. A method of treating pouchitiscomprising: administering to a patient with pouchitis an immunestimulatory amount of an agonist of CDw131 (the common beta subunit ofthe receptors for GM-CSF, IL-3, and Il-5).
 38. A method of preventing orreducing the risk of fistula recurrence, comprising: administering to apatient with Crohn's disease who has previously had a fistula, with animmune stimulatory amount of an agonist of CDw131 (the common betasubunit of the receptors for GM-CSF, IL-3, and Il-5), whereby the riskof recurrence of a fistula is reduced.
 39. The method of any of claims34-38 wherein the agonist is IL-3.
 40. The method of any of claims 34-38wherein the agonist is IL-5.
 41. The method of any of claims 34-36wherein the patient has mucosal inflammatory disease of at least one ofthe small intestine, colon, or rectum, and the amount of colonystimulating factor administered is sufficient to reduce the mucosalinflammation.
 42. The method of claim 41 wherein the amount of colonystimulating factor administered is sufficient to induce remission of themucosal disease.
 43. The method of any of claims 34-36 wherein thepatient has epithelial damage of at least one of the small intestine,colon, or rectum, and the amount of colony stimulating factoradministered is sufficient to repair the epithelial damage.
 44. Themethod of any of claims 34-36 wherein the amount of colony stimulatingfactor administered is sufficient to reduce the patient's symptoms. 45.The method of any of claims 34-36 wherein the patient has a fistula or aperianal abscess, and the amount of colony stimulating factoradministered is sufficient to reduce the fistula or perianal abscess.46. The method of any of claims 34-36 wherein the patient is inremission.
 47. The method of any of claims 34-36 wherein the patient hasreceived surgical therapy of affected portions of the gastrointestinaltract.
 48. The method of any of claims 34-36 wherein the patient has anextraintestinal manifestation of Crohn's disease and the amount ofcolony stimulating factor administered is sufficient to reduce theextraintestinal manifestation.
 49. The method of claim 48 wherein theextraintestinal manifestation is an inflammatory eye disorder.
 50. Themethod of claim 49 wherein the inflammatory eye disorder is selectedfrom the group consisting of: iritis, uveitis, and episcleritis.
 51. Themethod of claim 49 wherein the extraintestinal manifestation a skindisorder.
 52. The method of claim 51 wherein the skin disorder isselected from the group consisting of: pyoderma gangrenosum and erythemanodosum.
 53. The method of claim 48 wherein the extraintestinalmanifestation is a liver disorder.
 54. The method of claim 53 whereinthe liver disorder is primary sclerosing cholangitis.
 55. The method ofclaim 48 wherein the extraintestinal manifestation is bile duct disease.56. The method of any of claims 34-38 wherein a reduced dose of animmunosuppressive agent is also administered to the patient.
 57. Themethod of claim 56 wherein the agent is selected from the groupconsisting of: corticosteroid, 6-mercaptopurine, azathioprine, andmethotrexate.
 58. The method of claim 48 wherein the extraintestinalmanifestation is stomach inflammation.
 59. The method of claim 48wherein the extraintestinal manifestation is esophageal disease.